GENIUS JOURNAL (General Nursing Science Journal)
Vol. 6 No. 2 (2025): GENIUS JOURNAL

Factors Associated with Incomplete Electronic Medical Records by Nurses after the Transition from Manual Documentation

Dewi, Hesti Puspita (Unknown)
Maryana, Maryana (Unknown)
Hermain, Hermain (Unknown)



Article Info

Publish Date
25 Oct 2025

Abstract

Introduction: Electronic medical records are a crucial part of healthcare. Nursing staff have a crucial responsibility to document all nursing actions or care provided to patients. Incomplete medical records can impact the quality of care and patient safety. Objective: The purpose of this study was to determine factors associated with incomplete electronic medical records by nurses following the transition from manual documentation. Method: This type of research was conducted with a cross-sectional design through a quantitative method approach. The population in this study were all nurses in the inpatient ward at Dr. (H.C) Ir. Soekarno Regional General Hospital in 2025 with a total of 160 nurses and a sample of 125 people. The sampling technique used in this study was the Non-Probability Sampling Technique with the Quota Sampling method. Data analysis used univariate analysis and bivariate analysis with the chi-square test with a 95% confidence level (α = 0.05). Result: This study shows that there is a relationship between workload (p = 0.033, POR = 2.526), motivation (p = 0.003 and POR = 5.238) and attitude (p = 0.004, POR = 3.441) with incomplete electronic medical records by nurses after the transition to manual documentation. In the variables of age (p = 0.210) and length of service (p = 0.127) it was concluded that there was no relationship with incomplete electronic medical records by nurses after the transition to manual documentation. Conclusion: The suggestion from this study is the importance of maintaining and improving nurse motivation, maintaining nurse attitudes, regulating the distribution of nurse workload in inpatient rooms and conducting a refresher regarding the use of electronic medical records in the hospital environment.

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Journal Info

Abbrev

gj

Publisher

Subject

Education Health Professions Nursing Public Health

Description

Genius Journal is a scientific journal that disseminates research results on the development of science and technology in the field of nursing. This journal facilitates nurse researchers, nurse educators and nurse clinicians from around the world to share information on research findings and ...